2026-2027 Cox Mill Elementary Consent for Student Support Services

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Parental Consent for Support Services

Email *

Dear Guardian,

A North Carolina state law, N.C. Gen. Stat. § 115C-76.45, requires notification and parental consent for the delivery of school mental health services. This form offers you the opportunity to consent to such services as delivered by school Specialized Instructional Support Personnel (SISP) staff, which include school counselors, school psychologists, school social workers, and school nurses.

SISP members strive to meet the needs of all of our students by visiting classrooms, working with small groups and meeting with students to discuss age-appropriate topics such as getting along with others, staying safe, coping skills and learning how to be a successful student.

Your consent will allow the SISP team to provide these support services to your child. If you have any questions or concerns about this information, please contact a member of the SISP team.

I have reviewed the statement above regarding the purpose of this form.

Agreement/Consent for Services

• I authorize SISP staff to provide ongoing supportive individual and/or group interventions for my child.

• I understand that I will receive regular updates on provided services, progress toward goals, and information on additional resources if a higher level of support is warranted. I shall also receive notification when there are any changes in the delivery or monitoring of my student’s mental health services.

• I recognize that services delivered by school staff are not intended to be a substitute for mental health services offered by outside community providers.

• I reserve the right to revoke this consent at any time by contacting the school staff in writing.

• I understand that parental or legal guardian permission is required for ongoing supportive individual and/or group interventions and consent will be updated annually.

I agree /consent to supportive services for my child.

I do not agree /do not consent to supportive services for my child.

Please type in your child's first name. *

Please type in your child's last name. *

Please select your child's grade level. *

Kindergarten

First

Second

Third

Fourth

Fifth

Verification

Please accept my typed name in the box below to serve as my electronic signature authorizing SISP staff to provide ongoing supportive individual and/or group interventions for my child. *

A copy of your responses will be emailed to the address you provided.

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